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Has your doctor diagnosed you with congestive heart failure?*

YesNo

Please indicate which type of prescribed medications you are currently taking to treat your congestive heart failure:*

NoneOral (by mouth)IntravenousOral & Intravenous

Do you feel excessively fatigued and/or breathless when performing activities like taking a walk or going up the stairs?*

YesNo

Have you been implanted with a cardiac defibrillator (a device that delivers an electric shock if you go into cardiac arrest)?*

YesNo

Do you have an ejection fraction or EF (a measure of how much blood your heart pumps) of 35% or less?

YesNoI don't know

Do you have high blood pressure (is your blood pressure usually higher than 140 mmHg)?

YesNo

Have you been implanted with a left ventricular assist device (LVAD)?*

YesNo

You currently do not match Barostim’s eligibility criteria.

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First Name*

Last Name*

Email Address*

Phone Number*

Please enter a valid phone number.

Message

I am over the age of 18

By submitting this form, you (i) indicate that you have read and understand our Privacy Policy (ii) request that CVRx, Inc. share the information you have provided on the form with Barostim patient ambassador(s) in an attempt to match you with such an individual; (iii) consent to being contacted by such an individual using any contact information that you have provided using this form; and (iv) consent to receiving electronic communications from CVRx, Inc. regarding Barostim. Except as otherwise provided herein and in our Privacy Policy, we will not sell or transfer your contact information to any other party.

Information provided by Ambassadors does not constitute medical information. You always should speak to your health care provider regarding questions you may have about Barostim therapy or to see if Barostim is right for you. By requesting to be connected to an Ambassador, you understand that Ambassadors are volunteers and that CVRx does not monitor or control, nor is it responsible for, their statements. Ambassador experiences with Barostim therapy are their individual experiences only. Individual results will vary. In addition, while CVRx instructs Ambassadors not to disclose your personal information, there is no guarantee that this will not happen.

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